Variation in Network Adequacy Standards in Medicaid Managed Care

, , ,
The American Journal of Managed Care, June 2022, Volume 28, Issue 6

Medicaid managed care network adequacy standards exhibit significant heterogeneity across regions and specialties, potentially creating large variations in health care access and quality.

ABSTRACT

Objectives: To describe the types and breadth of network adequacy standards used by state Medicaid programs with managed care arrangements.

Study Design: Document analysis of Medicaid provider network reports, managed care plan contracts, access monitoring review plans, Medicaid services manuals, quality strategy reviews, and state statutes and regulations.

Methods: We analyzed 52 primary documents from 2017 to 2020, representing 39 of the 40 states (including the District of Columbia) with Medicaid managed care. We conducted descriptive analyses of network adequacy standards, variation in standards by type of provider, timely access standards, nonquantitative network access standards, and monitoring or enforcement plans.

Results: A majority (89.7%) of states applied time and distance standards for network adequacy, stratified by population size or geography. Time and distance standards ranged from 15 to 90 minutes for a primary care provider (mean, 44.7 minutes in rural areas and 28.9 minutes in urban areas) to 30 to 135 minutes for a cardiologist (mean, 72.1 minutes in rural areas and 40.4 minutes in urban areas). Most states also used timely access or appointment availability standards. Relatively few states applied other quantitative standards, such as provider to enrollee ratios, or provided detailed enforcement plans in cases of poor compliance.

Conclusions: Most states use travel time and distance to account for local contexts and geographies, but there is considerable variation across Medicaid programs. Several states do not publicize their network adequacy regulations, or they rely on qualitative standards despite federal requirements. For network adequacy to be meaningful, states must balance the tension between flexibility and accountability and ensure that regulations are monitored and enforced accordingly.

Am J Manag Care. 2022;28(6):288-292. https://doi.org/10.37765/ajmc.2022.89156

_____

Takeaway Points

Network adequacy refers to a health plan’s ability to provide a sufficient number and types of health care professionals and facilities to ensure reasonable access without delay. Under Medicaid managed care—the predominant form of coverage in Medicaid—states are given broad leeway to define network adequacy and access standards.

  • Most states use time and distance standards for network adequacy. However, there is wide variation in the use of other quantitative standards and the extent to which standards are enforced.
  • Time and distance standards vary widely across specialty types and geographic areas, from 15 to 90 minutes for a primary care provider (mean, 44.7 minutes in rural areas and 28.9 minutes in urban areas) to 30 to 135 minutes for a cardiologist (mean, 72.1 minutes in rural areas and 40.4 minutes in urban areas).
  • The 2020 Medicaid managed care final rule loosens network adequacy regulations. States will need to ensure that greater flexibility does not reduce accountability through monitoring and enforcement.

_____

Network adequacy is a simple concept that has proven complex to operationalize. Broadly speaking, network adequacy refers to the framework by which regulators determine whether plans provide a sufficient number and types of health care professionals and facilities to ensure reasonable access without delay. With little consensus on what constitutes “sufficient” and “reasonable,” there is enormous variation in how insurers and regulators interpret these standards. Recently, concerns about narrow networks1-3 and access to certain specialties4,5 have prompted state and federal regulators to produce new guidelines or modify existing rules that pertain to network adequacy.

One notable change, via the 2020 Medicaid managed care final rule, grants states more flexibility around the types of network adequacy standards used and the specific standards that are set. For example, the 2016 Medicaid managed care final rule required states to establish time and distance standards for 11 key types of providers.6 CMS recently removed the requirement that Medicaid programs use time and distance standards, instead allowing states to use any quantitative standard to define network adequacy. It is not yet clear what impact this policy change will have on the selection of network adequacy standards by states or on participation and compliance on the part of managed care organizations (MCOs). Nonetheless, it is likely that this policy will pertain to most Medicaid beneficiaries, at least 70% of whom are enrolled under managed care plans.7

Although some reports have relied on case studies of up to 14 states,8,9 there is no comprehensive assessment of the network adequacy standards currently used by state Medicaid programs. To address this gap, we conducted an environmental scan using primary documents on network adequacy standards in state Medicaid programs with managed care arrangements.10 Understanding how states are currently addressing network adequacy can inform how states may respond to recent regulatory changes.

DATA AND METHODS

From April to December 2020, we conducted a search for published network adequacy standards in states with full or partial Medicaid services provided through managed care organizations. We queried Google using both state name and branded Medicaid program name, if applicable, and the following terms: network adequacy, network standard, network access, timely access, provider network, provider access, access to care, and appointment availability. Of the 40 states (including the District of Columbia) with Medicaid managed care arrangements,7 all but 1 had publicly available documentation that described network adequacy rules.

We included the most recent version of the following primary documents: Medicaid provider network reports, timely access standards, managed care plan contracts, access monitoring review plans, Medicaid services manuals, quality strategy reviews, and state statutes and regulations. We excluded documents that were not linked to official state government, Medicaid program, or health plan websites or that did not pertain to Medicaid managed care specifically. A total of 52 documents were reviewed, spanning publication or most recent updated dates from 2017 (1 state) to 2020.

From each document, we extracted data on quantitative network adequacy standards, variation in standards by type of provider, timely access standards, nonquantitative network access standards, and monitoring or enforcement plans. The study team iteratively developed a data abstraction table that evolved as the primary documents were reviewed in progressive detail. Our data abstraction algorithm was piloted with 5 documents across 3 states, and the research team met to review, discuss, and change the data abstraction table as necessary to include relevant information for all states. We analyzed collated data using descriptive numerical summaries. For descriptive purposes, we used the following conventional definitions: “timely access” or “appointment availability standards” refers to any standards that identified a time frame for appointment availability; “time and distance standards” includes any consideration of the geographic location of providers, namely the maximum travel time and distance from a beneficiary’s residence to the nearest provider site.

We used cardiology as a comparator for network access standards that applied to a non–behavioral health specialty provider. When network adequacy standards identified “specialists” as a group without further specialty differentiation, we included those standards in our exhibits. We separately examined network adequacy standards for behavioral health, including substance use disorder (SUD).

RESULTS

Among 39 states (including the District of Columbia), 35 (89.7%) reported time and distance standards for network adequacy (Table 1). Thirty of those states stratified these quantitative standards by population size or geography and separately defined standards for different specialty groups. Seventy-two percent of states had separate time and distance standards defined for mental/behavioral health. However, only 37% had distinct standards for SUD treatment, which typically involved distinguishing among treatment settings, including acute detoxification, outpatient treatment, and residential treatment. Approximately half of the states had time and distance standards defined explicitly for dental care.

Most states (74.4%) also used appointment availability or timely access standards to set a minimum floor for appointment availability. In contrast, only approximately one-third of states with publicized network adequacy standards used provider to enrollee ratios. Approximately 25% of states applied a “provider choice” standard, requiring that enrollees have a choice of at least 2 providers within a given geographic area or travel time.

Of the 4 states that did not appear to have time and distance standards, 1 state used provider to enrollee ratios. All states had timely access standards. Three states used qualitative standards only, alluding to “sufficient” or “direct” access without specifying a minimum threshold.

Network adequacy standards varied significantly by state, provider type, and across rural vs urban regions (Table 2 and eAppendix Table [available at ajmc.com]). For example, maximum time and distance standards for a primary care provider ranged from 15 to 90 minutes, or 6 to 60 miles. Travel time standards to a primary care provider averaged 44.7 minutes in rural areas and 28.9 minutes in urban or metropolitan areas. The time and distance standards for a medical or surgical specialty provider were generally more forgiving. For cardiologists, these standards ranged from 30 to 135 minutes, or 15 to 100 miles (mean, 72.1 minutes in rural areas and 40.4 minutes in urban areas). Time and distance standards for behavioral health and SUD providers were comparable. For example, maximum travel time averaged 63.8 minutes in rural areas and 39.3 minutes in urban areas for behavioral health providers and 76.3 minutes in rural areas and 40.0 minutes in urban areas for SUD providers.

Similarly, timely access standards for primary care ranged from 10 to 45 days for a routine appointment and from 1 to 4 days for an urgent appointment. For a specialist appointment, maximum wait times ranged from 10 to 60 days for routine visits and from 1 to 5 days for urgent visits.

Notably, the majority of states publicized monitoring plans to track network adequacy across Medicaid managed care plans. For example, North Carolina required health plans to submit regular access plans and provider network data to demonstrate network adequacy. The state of Texas indicated that it analyzed provider network access for each managed care program quarterly, including conducting geospatial analysis annually to monitor distance standards and applying secret shopper methodology to evaluate timely access standards. Maryland and Minnesota required MCOs to submit provider network data as part of the contracting process or as a prerequisite to operating. Other states used external quality reviews to validate provider network data submitted by MCOs. However, only 9 states described a detailed network adequacy enforcement plan. These enforcement plans often cited “corrective” action for inadequate compliance without specifying what this action might entail.

DISCUSSION

Although most states appear to be using time and distance standards that consider local populations and geographies, there remains considerable variation in access standards across Medicaid managed care programs. Not all states make their network adequacy requirements publicly available, and others rely on qualitative standards despite federal requirements to the contrary.

In view of this existing variability, the 2020 Medicaid managed care final rule loosens requirements even further. In place of mandatory time and distance standards, CMS suggests several alternative quantitative standards that states may elect to use, including (1) minimum provider to enrollee ratios, (2) a minimum percentage of contracted providers that are accepting new patients, (3) maximum wait times for an appointment, and (4) hours of operation requirements (eg, extended evening or weekend hours).10 Our findings suggest that some states are already using alternative quantitative standards, although often in conjunction with more traditional time and distance standards. Thus, removing the requirement for time and distance standards may leave potential gaps in current efforts to monitor access to care.

More broadly, our comparison across states also raises questions about potential trade-offs between flexible vs rigid network adequacy standards. On one hand, more flexibility in access standards may allow health plans and regulators to meet the needs of heterogeneous populations and account for different Medicaid program characteristics, degrees of rurality, and constraints with workforce supply. Access standards for ophthalmologists in rural Iowa, for example, may look very different from those in the suburbs of Houston, and appropriately so. Greater flexibility in network adequacy standards may also allow states to take into account new modalities of health care delivery for which traditional time and distance standards do not apply. On the other hand, network adequacy standards that are so flexible as to lack meaning may inadvertently reduce access to care, exacerbating disparities across Medicaid programs and populations. Widely variable standards may also translate into highly variable health care experiences among Medicaid enrollees across states and weaken one important avenue by which states safeguard against provider networks that are too narrow and work to build provider capacity where needed.

More likely than not, network adequacy standards are necessary but insufficient for improving downstream access to care. Ndumele et al compared ratings of access to specialists for adult Medicaid and commercial enrollees before and after implementing specialty access standards in 5 states compared with controls, finding no significant self-reported changes in access.11 Our findings suggest one important reason: Current network adequacy standards largely rely on single dimensions of access, such as travel time or distance, without adequately reflecting availability, acceptability, or quality of care delivered.12 When it comes to telehealth, for example, the 2020 Medicaid managed care final rule allows each state to determine the criteria to be applied to telehealth providers and how such providers would be considered when evaluating network adequacy.10 In this context, the mere presence of telehealth providers may not be an appropriate criterion for network adequacy, particularly if telehealth access occurs at the expense of necessary in-person care or if telehealth has inequitable uptake across communities. Moreover, states or MCOs often rely on provider directories to monitor compliance with provider network regulations, but these directories are often inaccurate13,14 and may further limit the effectiveness of network adequacy standards at face value. Finally, a host of broader issues may affect states’ abilities to adopt stricter network adequacy requirements and MCOs’ abilities to meet them, including but not limited to provider shortages and low network participation.

Our data point to several areas where further research is needed, including the extent to which network adequacy standards are associated with changes in access to care and utilization. More investigation is also needed to understand the types of standards that are most effective in the context of specific population and health needs—for example, within rural vs urban and health resource shortage areas, and for specialties, such as psychiatry, that have traditionally raised network adequacy concerns within Medicaid.

Limitations

This study has important limitations. Although we used a systematic search strategy to capture key documents pertaining to states’ network adequacy standards, we cannot confirm that our search was complete. The absence of publicly available documentation does not mean that specific network adequacy regulations do not exist in particular states. Nonetheless, to our knowledge, this study represents the most comprehensive review to date of network adequacy standards in Medicaid managed care.

CONCLUSIONS

This environmental scan suggests significant heterogeneity in the definition and application of network adequacy standards in Medicaid managed care. Although network adequacy can be viewed as a necessary standard for ensuring access, more research is needed to clarify how these standards can be tailored to support access, quality, and budget constraints. As CMS grants states more flexibility in their use of network adequacy, it will be critical to monitor the implications for states’ responses and how these changes affect the Medicaid population.

Author Affiliations: Division of General Internal Medicine (JMZ), Department of Medicine (CJ), and Center for Health Systems Effectiveness (KJM), Oregon Health & Science University, Portland, OR; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (DP), Baltimore, MD.

Source of Funding: This work was supported by the National Institutes of Mental Health (1K08MH123624-01).

Author Disclosures: Dr Zhu has received consultant fees from Omada Health and grants from NIHCM Foundation on topics unrelated to this study. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (JMZ, CJ, KJM); acquisition of data (JMZ, CJ); analysis and interpretation of data (JMZ, DP, CJ); drafting of the manuscript (JMZ, DP, CJ); critical revision of the manuscript for important intellectual content (JMZ, DP, KJM); statistical analysis (JMZ); obtaining funding (JMZ); administrative, technical, or logistic support (JMZ, KJM); and supervision (JMZ, DP, KJM).

Address Correspondence to: Jane M. Zhu, MD, MPP, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239. Email: zhujan@ohsu.edu.

REFERENCES

1. Polsky D, Cidav Z, Swanson A. Marketplace plans with narrow physician networks feature lower monthly premiums than plans with larger networks. Health Aff (Millwood). 2016;35(10):1842-1848. doi:10.1377/hlthaff.2016.0693

2. Zhu JM, Zhang Y, Polsky D. Networks in ACA marketplaces are narrower for mental health care than for primary care. Health Aff (Millwood). 2017;36(9):1624-1631. doi:10.1377/hlthaff.2017.0325

3. Yasaitis L, Bekelman JE, Polsky D. Relation between narrow networks and providers of cancer care. J Clin Oncol. 2017;35(27):3131-3135. doi:10.1200/JCO.2017.73.2040

4. Schleicher SM, Mullangi S, Feeley TW. Effects of narrow networks on access to high-quality cancer care. JAMA Oncol. 2016;2(4):427-428. doi:10.1001/jamaoncol.2015.6125

5. Dossani RH, Kalakoti P, Nanda A, Guthikonda B, Tumialán LM. Is access to outpatient neurosurgery affected by narrow insurance networks? results from statewide analysis of marketplace plans in Louisiana. Neurosurgery. 2019;84(1):50-59. doi:10.1093/neuros/nyx632

6. CMS, HHS. Medicare program; prospective payment system and consolidated billing for skilled nursing facilities proposed rule for FY 2017, SNF value-based purchasing program, SNF quality reporting program, and SNF payment models research. Fed Regist. 2016;81(79):24230-24280.

7. Medicaid Managed Care Market Tracker. Kaiser Family Foundation. Accessed December 19, 2019. https://www.kff.org/data-collection/medicaid-managed-care-market-tracker/

8. Lipson DJ, Libersky J, Bradley K, Lewis C, Siegwarth AW, Lester R. Promoting access in Medicaid and CHIP managed care: a toolkit for ensuring provider network adequacy and service availability. CMS. April 2017. Accessed January 4, 2021. https://www.medicaid.gov/medicaid/downloads/adequacy-and-access-toolkit.pdf

9. Network adequacy in managed care. Medicaid and CHIP Payment and Access Commission. December 2018. Accessed April 30, 2021. https://www.macpac.gov/publication/network-adequacy-in-managed-care/

10. CMS, HHS. Medicaid program; Medicaid and Children’s Health Insurance Program (CHIP) managed care. Fed Regist. 2020;85(220):72754-72844.

11. Ndumele CD, Cohen MS, Cleary PD. Association of state access standards with accessibility to specialists for Medicaid managed care enrollees. JAMA Intern Med. 2017;177(10):1445-1451. doi:10.1001/jamainternmed.2017.3766

12. Hall MA, Ginsburg PB. A better approach to regulating provider network adequacy. Brookings. September 2017. Accessed May 14, 2021. https://www.brookings.edu/wp-content/uploads/2017/09/regulatory-options-for-provider-network-adequacy.pdf

13. Busch SH, Kyanko KA. Incorrect provider directories associated with out-of-network mental health care and outpatient surprise bills. Health Aff (Millwood). 2020;39(6):975-983. doi:10.1377/hlthaff.2019.01501

14. Haeder SF, Weimer DL, Mukamel DB. Secret shoppers find access to providers and network accuracy lacking for those in marketplace and commercial plans. Health Aff (Millwood). 2016;35(7):1160-1166. doi:10.1377/hlthaff.2015.1554